Faced with limited funds and changing health care laws, the state is making HIV tests more expensive and potentially nonexistent in small or rural Kansas communities.

Among the paternity and drug tests at Walgreens, customers will now find Oraquick, the first over-the-counter in-home HIV test. At about $40, Oraquick is an important step toward making HIV (human immunodeficiency virus) testing more accessible. But, faced with limited funds and changing health care laws, state officials are implementing policies that make the tests more expensive and potentially nonexistent in small or rural Kansas communities.

In late November, the Kansas Department of Health and Environment (KDHE) sent letters to the majority of Kansas counseling and testing providers, most of them rural health departments. The letter stated that as of Jan. 1, 2013, the agency would no longer "provide rapid or oral test kits, nor process blood or oral specimens submitted to the Kansas Department of Health and Environment Lab" for the purposes of HIV diagnosis. This gave providers like the Reno County Health Department (RCHD) five weeks, including the holidays, to plan for testing and services previously provided for free to continue after the new year.

According to the Kansas Health Institute (KHI), 40 health departments received free HIV services from the state in the past. That number is now 10.

Neita Christopherson, RCHD associate director, said now, those wanting an HIV test will pay a fee that is yet to be determined. It's a concern for the department, Christopherson said.

"Unfortunately there may be those who feel they wouldn't be able to afford that test. Then they also miss out on our counseling and education," she said.

"But we're available. Those doors would be open."

Last year, Julia Hulsey, RCHD director, said the department administered about 200 tests, all of which were free. Lori Gilliam, clinical director of the Ford County Health Department, said her agency administered five HIV tests last year. She said previously people were charged for HIV tests on a sliding scale according to income. Like Christopherson, Gilliam said she was concerned that making people pay more would discourage them from getting tested.

"We will try to keep this cost as low as we can for the client, but there will be a charge," she said.

While some health departments will be able to work out ways to continue HIV testing, Michelle Ponce, executive director of the Kansas Association of Local Health Departments, said she predicted other agencies will have to cut HIV services altogether. This, she said, is a major issue.

"What we're really talking about is potentially decreased access to services. If there's not an entity in a community able to provide HIV testing on a basis which clients can afford, it's not going to be done," Ponce said.

"You can make an assumption that with lower testing levels, there will be lower treatment levels."

The reason for the cut in state services, said Ralph Wilmoth, director of the KDHE HIV/AIDS program, was multifaceted. Because funding for HIV testing and services is down in general, the Center for Disease Control and Prevention (CDC) and KDHE chose to focus resources where most needed, Wilmoth said. This means places with a 0.1 percent positivity rate for HIV testing in healthcare settings and a 1 percent positivity rate of HIV testing non-healthcare settings. Wilmoth said the diagnosis rate in many Kansas counties, including Reno, is so low, it didn't make sense for HIV/AIDS funding to go toward them.

"If you have a county, and it's one event (HIV diagnosis) a year, and then you have two events in one year, that means you had a 100 percent increase," Wilmoth said. "That really complicates the idea when you're trying to use rates for analysis."

To compensate for the low numbers, Kansas monitors HIV activities according to region. In 2010, 2,750 people in Kansas were living with HIV- 846 of them in region 8, which includes Reno and Sedgwick counties. The vast majority of those people were in Wichita, Wilmoth said.

Another reason for the cut in funding, he said, was the federal Affordable Care Act, which is expected to give access to HIV testing to those who previously didn't have it.

"We know more people will be able to access care services than more people have had in the past," Wilmoth said.

"It's a philosophical shift at that level of saying we have another system that does this. ... It's not an appropriate use of federal dollars."

Although she understands the decision, it's definitely not ideal for most of Kansas, said Donna Sweet, University of Kansas director of internal medicine education at Via Christi Regional Medical Center in Wichita. Sweet has been the principal investigator for the Mountain Plains AIDS Education and Training Center since 1988.

"Certainly it's going to make an impact. People who are poor generally don't have the money to pay for anything that is not free," she said.

Sweet said because of the decision to cut funding in certain areas, rural communities would see a decline in testing for HIV, something she said she found difficult to accept. Sweet said if a person with HIV isn't tested or is waiting longer to get tested, the individual wouldn't know whether he or she is spreading the virus, and the majority of new infections come from people who don't know they're infected. Sweet also said that small-town culture might prevent someone from being open with their primary care physician about activates that could put them at risk, and at the same time, physicians in rural communities might not recognize the signs of HIV. This, she said, makes access to free and preventative testing only more important.

"There's a lot of reasons people feel they can't be completely honest when everyone knows everyone," she said.

Access to HIV tests isn't the only thing at risk. According to an October 2012 KHI news release, funding from a federal program that helps county health departments prevent infertility in women by testing for Chlamydia and gonorrhea is also likely to go away after January 2014. Combined, the two sexually transmitted diseases are the leading cause if infertility, according to the CDC. The funding is going away, again, with the assumption more people will be covered by the Affordable Care Act.

"A lot of health departments today are dealing with people who won't be eligible for health insurance under any circumstances - the undocumented folks, for example," Greg Stephenson said in the KHI release. Stephenson is head of the clinical services division at the Wyandotte County Public Health Department.

While Sweet acknowledged more people would have access to HIV testing because of the Affordable Care Act and the ability to purchase tests at pharmacies, the decision is still leaving out one of the most vulnerable populations.

"The poor without insurance are left out," she said. "I find that very difficult to accept."